Success with Heart Failure

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Diagnosis and Evaluation
J. Thomas Heywood Director, Cardiomyopathy
Program Loma Linda University Medical Center Loma
Linda, California
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Neurohormonal Activation in Heart Failure
Myocardial injury to the heart (CAD, HTN, CMP,
valvular disease)
Initial fall in LV performance, ? wall stress
Activation of RAS and SNS
Fibrosis, apoptosis,hypertrophy,
cellular/molecular alterations,myotoxicity
Peripheral vasoconstriction Sodium
retention Hemodynamic alterations
Remodeling and progressive worsening of LV
function
Heart failure symptoms
Morbidity and mortality Arrhythmias Pump failure
FatigueActivity altered Chest
congestionEdemaShortness of breath
RAS, renin-angiotensin system SNS, sympathetic
nervous system.
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Pathophysiology of HF
Fall in LV Performance
Myocardial Injury
Activation of RAAS and SNS (endothelin, AVP,
cytokines)
ANP BNP
Myocardial Toxicity Change in Gene Expression
Peripheral Vasoconstriction Sodium/Water
Retention
Remodeling and Progressive Worsening of LV
Function
HF Symptoms
Morbidity and Mortality
Shah M et al. Rev Cardiovasc Med. 20012(suppl
2)S2
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Definition of Heart Failure

• Heart failure is a syndrome resulting from the
  inability of the heart to pump sufficient blood
  for the bodys peripheral requirements in oxygen
  and cell nutrients, at rest and during effort

Congestive Heart Failure. 2000. Pg 41
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Early Response of PCW but Not CI Predicts
Subsequent Mortality in Advanced Heart Failure
Total Mortality Risk ()
Total Mortality Risk ()
60
60
50
50
PCW gt 16 mmHg
40
40
Cardiac Index gt 2.6 L/min-M2
30
30
199
PCW lt 16 mmHg
20
20
Cardiac Index lt 2.6 L/min/M2
236
10
10
220
257
P0.001
PNS
0
0
0
6
12
18
24
0
6
12
18
24
Months
Months
Final hemodynamic measurement in 456 advanced HF
patients after tailored vasodilator therapy
Fonarow. Circulation. 199490I-488.
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Definition of Heart Failure

• Clearly an inadequate definition
• Most patients appear to have a near normal CO at
  rest
• Does not deal with the congestive symptoms which
  cause the more common symptoms of heart failure
• Certainly does not adequately describe patients
  with diastolic dysfunction

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AHA/ACC Guidelines for the Evaluation and
Management of Chronic Heart Failure

• A. Definition of HF
• Heart failure is a complex clinical syndrome
  that can result from any structural or functional
  cardiac disorder that impairs the ability of the
  ventricle to fill with or eject blood.
• The cardinal manifestations of HF are dyspnea and
  fatigue, which may limit exercise tolerance, and
  fluid retention, which may lead to pulmonary
  congestion and peripheral edema.

ACC/AHA Guidelines 2001
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Final Common Pathway inHeart Failure

• Cardiac dysfunction leads to elevated filling
  pressures
• Right atrial pressure increases from 2-5 to gt
  7-20 mmHGthis leads to ascites, liver congestion
  and peripheral edema
• Left atrial pressure increases from 5-12 to
  gt18-40 mmHGthis results in dyspnea, pulmonary
  edema and pleural effusions

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So a primary goal in making a diagnosis of heart
failure is discovering signs and symptoms of high
right and left atrial pressures
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Difficulties in DiagnosingHeart Failure

• Can be a wide range of presentations
• Many of the symptoms of heart failure overlap
  with other disease states such as COPD, obesity,
  nephrotic syndrome, drug- induced edema,
  cirrhosis and sleep apnea
• How to effectively and efficiently differentiate
  between these entities?

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Classic Symptoms ofHeart Failure

• Dyspnea on exersion
• Lower extremity edema
• Orthopnea
• Paroxysmal nocturnal dyspea
• Fatigue

Low cardiac output
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How Good are the Symptoms for Identifying High
Filling Pressures and Heart Failure?

• Orthopnea is very specific to heart failure the
  majority of patients with orthopnea have high
  filling pressures
• Other symptoms are less helpful but should still
  be asked

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Signs of Heart Failure

• Elevated neck veins (jugular venous pressure)
• Positive abdominojugular reflux
• Rales or evidence of pleural effusion
• An S3
• Ascites
• Lower extremity edema

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Bedside Cardiovascular Examinationin Patient
with Severe CHF

• Did careful physical exam on heart failure
  patients about to undergo a right heart cath
• 52 patients, mostly NYHA III, average EF 18

Butman et al. J Amer Coll Cardiol. 10/93
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Bedside Cardiovascular Examinationin Patient
with Severe CHF

• If rales were present, all had a wedge pressure
  gt18, very specific
• However only 9 of 37 with a wedge pressure gt18
  had rales, very insensitive
• Soclear lung fields tell you very little about
  the fluid status in heart failure

Butman et al. J Amer Coll Cardiol. 10/93
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Bedside Cardiovascular Examinationin Patient
with Severe CHF

• Only 3 of 15 with a low wedge had a high JVP or
  positive adbominojugular reflux test, spec of 80
  
• 30 of 37 with a high wedge had either a high JVP
  or positive abdominojugular reflux test,
  sensitivity of 81
• So a careful examination of the neck veins is the
  best physical exam technique for determining the
  fluid status in heart failure

Butman et al. J Amer Coll Cardiol. 10/93
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JVP lt7 JVP lt7 JVP? 7
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The Abdominojugular Test Techniqueand
Hemodynamic Correlates
40
35
30
Wedge Pressure
25
20
15
10
5
0
Negative AJR
Positive AJR
Ewy GA. Ann Int Med. Sept 88.
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The most reliable signs for elevated left-sided
filling pressures then are the presence of an
elevated JVP (gt7 cm H2O) or positive
abdominojugular reflux (AJR)
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So... if a patient has symptoms compatible with
heart failure (especially orthopnea) and signs of
fluid overload a diagnosis of heart failure is
reasonably certain
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Natriuretic PeptidesThe Heart as a Secretory
Organ
Atrial stretch receptors link blood volume to
renal function Distension of a balloon catheter
in atria of dogs resulted in diuresis- Henry,
et al. (1956) Secretory granules discovered in
the atria- Kisch (1956)- Jamieson and Palade
(1964) BNP was characterized by amino acid
sequence and DNA clones(Sudoh, et al. 1988
Seilhamer, et al. 1989).
Jamieson, Palade. J Cell Biol. 196423151.
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Bedside B-Type Natriuretic Peptide in the
Emergency Diagnosis of Heart Failure With Reduced
or Preserved Ejection Fraction
J Am Coll Cardiol. 2003412010 -2017.
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Bedside B-Type Natriuretic Peptide in the
Emergency Diagnosis of Heart Failure With Reduced
or Preserved Ejection Fraction
J Am Coll Cardiol. 2003412010 -2017.
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BNP and Diastolic Dysfunction
Maisel. Circulation. Feb 2002
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BNP lt 100 HF unlikely BNP gt100 but lt 500 use of
clinical judgement BNP gt 500 HF likely
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Causes of a Increased BNP

• LV systolic dysfunction
• LVH with diastolic abnormalities
• Significant pulmonary embolism
• Cor pulmonale
• Pulmonary HTN
• Aging (modest increases)
• Renal insufficiency

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BNP and BMI
BNP

• 634 patients from the BNP study with confirmed
  diagnosis of HF
• Significant adjusted negative correlation between
  BMI and BNP

BMI
J Amer Coll Cardiol. 2003138A.
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Val-HeFT Trial
Baseline BNP Levels
Note Multiply level by 1.5 to compare with
Biosite BNP assay
Anand. J Card Failure. Sept 2002
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What BNP tells us dependson the question that is
asked

• Does the ER patient have decompensated HF?
• Does an outpatient have LV dysfunction?
• What is the prognosis of the patient?

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New Approach to the Classification of Heart
Failure
Hunt SA et al. J Am Coll Cardiol.
20013821012113.
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If CHF is Suspected, It Should Be Confirmed With
an ECHO

• Most complete and cost-effective first step
• Confirms diagnosis, quantifies severityof
  disease
• Rules out fixable valvular lesions
• Can give hemodynamic information such as PA
  pressure, RA pressure and approximate wedge
  pressure

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What Does The Echo Tell UsBeyond The Ejection
Fraction??

• Valvular heart disease
• Chamber size, wall motion abnormalities, LV Fx,
  LVH, RVH
• Hemodynamics, RA pressure, PA pressure, estimated
  filling pressures, cardiac output
• RV function
• Valvular diseasesignificant leaks(at least
  moderate) and stenosis of valves

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Classification of Heart Failure

• Dilated
• Ischemic, viral, hypertensive, drug induced
  (ETOH, adriamycin, amphetamines), peripartum,
  inborn error of metabolism (muscular dystrophy),
  hematochromatosis
• Restrictive
• Amyloid, pericardial constriction, HCM,
  idiopathic, endocardial fibrosis, eosinophilic
  heart disease, hematochromatosis, sarcoid,
  radiation
• High Output
• Hyperthyroidism, anemia, thiamine
  deficiency,Pagets disease, AV fistula,

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Three Major Forms of Heart Failure Seen in
Clinical Practice

• Decompensated heart failure with signs and
  symptoms of fluid overload, peripheral edema,
  pulmonary congestion, etc and low EF SYSTOLIC
  DYSFUNCTION-Stage C HF
• Decompensated heart failure with normal EF and
  Normal valves-DIASTOLIC DYSFUNCTION-Stage C
  Diastolic HF
• Compensated LV dysfunction
• Below normal ejection fraction but without signs
  of fluid overload, symptoms may be minimal-Stage
  B HF

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Laboratory Testing

• Routine chemistry, CBC, urinalysis, Ca, Mg,
  lipids, BUN, creatinine, LFTs
• Thyroid studies, ferritin
• CXR
• 12 Lead EKG
• Viral titers (low yield)
• HIV, connective tissue and pheochromocytoma
  testing when these are suspected

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Should the Patient Undergo Coronary Angiography?

• Approximately 60 of patients with HF have
  coronary disease
• Patients with CP and CAD may improve
  symptomatically and prognostically when
  revascularized
• Recommendation for angiography (AHA/ACC)
• Patients with CP
• Young patients with new onset HF (exclude
  congenital abn)
• Possibly for patients without CP

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Should the Patient Undergo Myocardial Biopsy?

• Approximately 1/3 of patients with HF have no
  identifiable cause
• Some of these may be present on myocardial biopsy
  (amyloid, hemochromatosis, myocarditis,
  adriamycin induced, Giant Cell myocarditis)
• Most biopsies findings are non specific
• Even with a positive finding, does not materially
  effect treatment
• Thus, endomyocardial biopsy is not indicated in
  the routine evaluation of cardiomyopathy.

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Role of the Cardiologist inHF Evaluation

• Confirm or dispute the diagnosis(especially
  diastolic HF)
• Rule out treatable causes
• Ensure that patient is on appropriate
  evidence-based therapy
• Help patient with life decisions, prognosis
• Make decisions about cardiac cath, surgical
  intervention, device implantation and cardiac
  transplant

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Prognostic Value of Glomerular Filtration Rate in
Patients With Heart Failure
4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0
1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3
Proportion survival
Proportion survival
GFR (mL/min) LVEF ()
0 250 500 750 1000 1250
gt76 59-76 44-58 lt44
gt30 26-30 20-25 lt20
Days
N19-6 GFRcglomerular filtration rate estimated
from serum creatinine, LVERleft ventricular
ejection fraction Hillage HL et al. Circulation.
2000102203-210.
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Survival in HF patients with reference to
BUNLoma Linda Cardiomyopathy Program
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The Prognostic Importance of Different
Definitionsof Worsening Renal Function in CHF
Sensitivity
100
Specificity
80
Risk of death or Hospitalization gt 10 days
60
40
20
0
Increase in Creatinine
Gottlieb S et al. J Card Failure. 6/02.
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Inpatient Mortality From ADHERE Registry Based
on Admission BUN, Creatinine and BP
lt
BUN 43 (n32220)
lt
lt
?
SBP 115 (n6697)
15.30 (n-1863)
5.63 (n-4834)
Cr 2.75 (n-1862)
lt
19.76 (n-592)
13.23 (n-1270)
Analysis of patients in the National Acute
Decompensated Heart Failure National Registry
(ADHERE) BUNblood urea nitrogen, Crserum
creatinine, SBP-systolic blood pressure Fonarow
GC et al. J Cardiac Fail 20039(suppl 1)S79.
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Degree of Renal Damage in Patients Admitted for
Decompensated HF
Severe
Kidney Damage
100,000 Admissions ADHERE
Mild
gt90
60-89
30-59
15-29
gt15
eGFR